Provider Demographics
NPI:1851487490
Name:EVANS - CONSTANTZ, ELAINE
Entity Type:Individual
Prefix:DR
First Name:ELAINE
Middle Name:
Last Name:EVANS - CONSTANTZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 E UNION ST
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101
Mailing Address - Country:US
Mailing Address - Phone:626-793-0441
Mailing Address - Fax:626-584-5792
Practice Address - Street 1:615 E UNION ST
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101
Practice Address - Country:US
Practice Address - Phone:626-793-0441
Practice Address - Fax:626-584-5792
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG433111207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95-4012218OtherTIN
CA95-4012218OtherTIN